HospitalInspections.org

Based on record review and interview, the Board of Trustees (facility ' s governing body) failed to oversee the facility ' s grievance process. Patient grievances were not being reported to the Board of Trustees.

Findings include:

Review of facility policy, " Patient Complaints/Grievances, " revealed the following: " Data on grievances is incorporated into the hospital ' s quality assessment and performance improvement program (QAPI). "
AND
" Summary reports of grievances are presented to the PI (Performance Improvement) Council and the Board of Directors. The PI Council integrates grievance information into the organization ' s performance improvement program. "

Review of the facility ' s grievance tracking log for 2011 revealed 78 grievances had been recorded as of 8/24/2011.

Review of Quality Committee meeting minutes of January-July 2011 failed to reveal any discussion of facility grievances.

Review of Board of Trustees meeting minutes of January-July 2011 failed to reveal any discussion of facility grievances.

In an interview on 8/24/2011 at 1:15pm in the Administration Conference Room, staff #2 confirmed that grievance information was not being reported to the Quality Committee.

In an interview on 8/24/2011 at 2:43pm in the Administration Conference Room, staff #5 confirmed that grievance information was not being reported to the Board of Trustees. Staff #5 reported that grievance information had not been reported to the Board for at least the past 10 years (staff #5 ' s tenure at the facility).